The topic: “Unilateral Do-Not-Attempt Resuscitation Orders In A Large Academic Hospital.” These are situations where “clinicians withhold advanced cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest despite objections of patients or their surrogates.” The presenters indicate that “The ethics committee at Massachusetts General Hospital has had a unilateral DNR policy since 2006.” Patients allowed to die against their or their surrogates’ will is news, right? Let’s see if anyone in the press cares. (So far: No.) A full description of the presentation, relevant background, and Smith’s reaction follow the jump.

Here is the presentation description found at the conference’s web site (search here on “unilateral” to replicate):

According to a 2007 CHEST Journal article (“The Ethics of Unilateral ‘Do Not Resuscitate’ Orders: The Role of “Informed Assent’”), there are “three categories of decisions to withhold or withdraw life-sustaining therapies that clinicians believe are clearly not indicated,” and “the concept of informed assent is not equally relevant for all three categories” (bolds are mine throughout the rest of this post):

The first category is withholding treatments that patients or family members are not likely to expect for the patients’ specific condition (for example an exploratory laparotomy or activated protein C for a moribund patient with severe septic shock and multiple organ failure); and, accordingly, clinicians need not discuss each treatment withheld if they do not regard it as medically indicated (although clinicians would be obliged to discuss such treatment if a patient or family member takes the initiative to inquire). In this category, decisions about medical futility are commonly made unilaterally …

The second category is withholding treatments or procedures that are clearly not indicated but that most patients or families have come to expect. We believe clinicians are obliged to discuss such interventions on their own initiative. Cardiopulmonary resuscitation is currently in this category. It may be that specific patients or families do not in fact expect this intervention. But the expectation is so widespread in our contemporary culture that clinicians should assume that the intervention is expected unless the patient or family indicates otherwise.

The third category is withdrawing a therapy that has already been started but which due to the patient’s clinical course is no longer indicated. Although many medical ethicists conclude that withholding and withdrawing life-sustaining treatments are ethically and legally equivalent, decisions about withdrawing interventions that clinicians have previously viewed as potentially beneficial often have a different and more powerful impact on patients and families than decisions not to initiate therapies in the first place. Accordingly, communication with families about withdrawal decisions should take account of those differences. As in the second category, clinicians should assume that patients or families expect interventions to be continued, once they are begun, unless the patient or family indicates otherwise.

For these second and third categories, we believe that obtaining informed assent to withhold or withdraw interventions is an ethically acceptable alternative to insisting that patients or families always bear the full burden of explicit consent.

Note the clear statement that cardiopulmonary resuscitation is currently something “most patients or families have come to expect.” Of course it is. Therefore, Mass General’s claimed unilateral decisions NOT to attempt it in certain instances without informing patients or their families clearly crosses the line of medical practitioners secretly deciding who will live and who will die, i.e., a death panel.

I wonder if unilateral DNRs are covered in the “Critical Care Handbook of the Massachussetts General Hospital”?

Smith’s reaction:

If I read this correctly, thirty-eight percent of those upon whom the unilateral DNRs appear not to have been at the end stage of a terminal disease:

Patients for whom unilateral DNR was recommended were more likely to have conditions judged to be endstage rather than potentially reversible (62% versus 41%, p=0.05).

And who can be surprised that non whites were more likely to have an involuntary DNR imposed?

This is medical tyranny.

So there’s even a potential “minorities most affected” aspect to all of this. So I’m sure the establishment press will be all over this.

Well, let’s hope for the best, but don’t hold your breath. The press’s performance in chronicling the culture of death’s forward march has been abysmal for many years. They may see the likelihood that such arbitrary and secret decisions might be even more strongly insulated from scrutiny in the future under Obamacare as a feature and not a bug.

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